Sunday, August 11, 2013

ROCHESTER, N.Y. -- Hospitals in New York have improved the quality of many of their services over the past several years, but patients are at increased risk of infections during their stay, according to a watchdog group that grades the state's hospitals.

Hospitals on the list had a higher number of better-than-average ratings for results in such conditions as heart attack, stroke, heart failure, hip fracture and a variety of safety indicators.

Highland Hospital in Rochester, Monroe County, was among 17 placed on the watch list. It had a worse-than-average mortality rate in four of the seven mortality measures for which there was enough data to analyze.

Data from more than 200 hospitals in the state were analyzed.

The current report is based on data from 2011 that hospitals used for patient billing and internal quality. The data covers all hospital patients, unlike other quality assessments that consider only Medicare patients, said Niagara Health Quality Coalition president and chief executive officer Bruce CQ Boissonnault.

The data cover a range of procedures and conditions, and put the number of procedures performed at the hospital into the context of a minimum threshold. It is risk-adjusted, which allows for comparison among hospitals regardless of how sick the patients are.

Consumers can search either by condition or procedure, or they can compare hospitals in their area or across the state.

"Consumers are looking for valuable, neutral independent information," Linda Joseph, chairwoman of NHQC's consumer committee and owner of a small business, said during a conference call last week.

Boissonnault said patients should discuss the report with their doctor and not make a decision on their own about where to seek care.

"A lot of times their doctors don't know this information," he said. "They don't know that the hospital to which they refer has a statistically significant worse mortally rate in the thing that the patient is being referred for or could be referred for. We like that, too. Then the doctor puts pressure on the hospital to improve."

Since the nonprofit organization released its first report in 2002, the statewide mortality rate has improved by 50 percent and several indicators of patient safety have also gotten better, Boissonnault said.

But hospital-acquired infections such as sepsis continue to be a concern. The rate of sepsis increased slightly from 2004 to 2011. "I see the trend as alarming," he said.

Unlike other measures in the report card, stopping infections may take community approaches, he said.

Boissonnault said that because patients travel among hospitals, as well as nursing homes, a comprehensive approach is needed.

"The chain of infection control is no stronger than its weakest link," he said.

Violating a patient’s trust and placing them at risk through fraudulent abuse of our nation’s health care system is deplorable and a crime which the FBI takes most seriously.

Robert D. Foley III, FBI Special Agent in Charge

Washington

Oakland County Doctor And Owner Of Michigan Hemotology And Oncology Centers Charged In $35 Million Medicare Fraud Scheme

August 6, 2013

Dr. Farid Fata, 48, of Oakland Township, Michigan, was arrested this morning and charged in a criminal complaint for his role in a health care fraud scheme which involved submitting false claims to Medicare for services that were medically unnecessary, including chemotherapy treatments.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Barbara L. McQuade of the Eastern District of Michigan, FBI Special Agent in Charge Robert D. Foley III and Special Agent in Charge Lamont Pugh of the Health and Human Services Office of Inspector General (HHS-OIG) made the announcement.

“Dr. Fata allegedly perpetrated a brazen and dangerous fraud that time and again jeopardized his patients’ wellbeing,” said Acting Assistant Attorney General Raman. “The conduct alleged today is chilling, with the defendant endangering patient safety through misdiagnoses, over- or mis-prescription of chemotherapy and other treatments, and delay of hospital care for patients with serious injuries. Through the work of our dedicated prosecutors and agents, today we have taken swift action to safeguard patient safety and hold the defendant to account.”

“Our first priority is patient care,” said U.S. Attorney McQuade. “The agents and attorneys acted with great attention to detail to stop these allegedly dangerous practices as quickly as possible, and we have set up a victim hotline so that patients can access their files and get questions answered.”

“Violating a patient’s trust and placing them at risk through fraudulent abuse of our nation’s health care system is deplorable and a crime which the FBI takes most seriously,” said FBI Special Agent in Charge Foley. “The FBI remains committed to the arrest and prosecution of those who commit health care fraud.”

“The conduct alleged in this complaint is serious, not only in terms of potential Medicare dollars improperly obtained, but patient safety as well,” said HHS-OIG Special Agent in Charge Pugh. “The OIG will aggressively investigate allegations of this nature in order to ensure the safety of Medicare patients and to protect vital taxpayer dollars.”

According to the complaint, Dr. Fata owns and operates Michigan Hematology Oncology Centers (MHO), which has offices in Clarkston, Bloomfield Hills, Lapeer, Sterling Heights, Troy and Oak Park. It was through MHO that Dr. Fata allegedly submitted fraudulent claims to Medicare for medically unnecessary services, including chemotherapy treatments, Positron Emission Tomograph (PET) scans and a variety of cancer and hematology treatments for patients who did not need them. In the course of the scheme, Dr. Fata falsified and directed others to falsify documents to justify cancer treatments for billing purposes. MHO billed Medicare for approximately $35 million dollars over a two-year period, approximately $25 million of which is attributable to Dr. Fata.

The complaint further alleges that Dr. Fata directed the administration of unnecessary chemotherapy to patients in remission; deliberate misdiagnoses of patients as having cancer to justify unnecessary cancer treatment; administration of chemotherapy to end-of-life patients who would not have benefitted from the treatment; deliberate misdiagnoses of patients without cancer to justify expensive testing; fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments, and distribution of controlled substances to patients without medical necessity or through administering the drugs at dangerous levels.

Dr. Fata will be making his initial appearance in federal court this afternoon at 1 p.m. in Detroit.

Patients who have questions concerning their medical records and/or information regarding this investigation and prosecution can call the United States Attorney’s Office Information Line at 888-702-0553.

The case is being prosecuted by Assistant Chief Catherine Dick, supervisor of the Detroit Medicare Fraud Strike Force and Trial Attorney Matthew Thuesen of the Department of Justice as well as Sarah Resnick Cohen, Deputy Chief of the Health Care Fraud Unit at the U.S. Attorney’s Office, and Justin Bidwell, Special Assistant United States Attorney. The investigations were conducted jointly by the FBI and HHS-OIG, along with the assistance of the Michigan Attorney General’s Office.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion. In addition, HHS’s Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

By ZIVA BRANSTETTER World Enterprise Editor on Aug 10, 2013, at 2:22 AM Updated on 8/10/13 at 4:15 AMMore than 50 Oklahoma hospitals, including all of Tulsa's major hospitals, have been fined by the federal government for Medicare patients who return for treatment within 30 days of an inpatient stay.

A provision of the Affordable Care Act, the financial penalties are part of a larger effort by the federal government to pay hospitals based on the quality of care they provide rather than the number of patients they treat. The readmission penalties, also levied last year, have sparked new efforts by hospitals statewide to help patients have a smooth recovery after leaving.

Among the Tulsa hospitals fined were St. John Medical Center, Oklahoma State University Medical Center, two Saint Francis hospitals and two Hillcrest Medical Center locations, a Tulsa World analysis of federal data shows.

The fines come in the form of deductions ranging from zero to 2 percent from future Medicare payments to the hospital.

The hospitals were penalized if patients treated for three conditions - heart attack, heart failure or pneumonia - were discharged and then admitted to any hospital within 30 days.

Because the Medicare program relies on tax dollars, ultimately taxpayers face higher bills when patients are readmitted. A Medicare advisory board has estimated that avoiding one in 10 readmissions could save $1 billion or more.

The readmission fines were levied against 2,225 hospitals nationwide, about two-thirds of all hospitals. Statewide, 53 out of 91 hospitals received penalties.

Dr. Peter Aran, senior vice president of quality for Saint Francis Health System, said the program came about after studies showed a high number of Medicare patients returning to the hospital after inpatient stays.

"It shocked the government that one in five patients had to come back to the hospital (within one month), and we were funding that. At the 12-month interval, one out of every two patients ... came back," Aran said.

Cheena Pazzo, a spokeswoman for St. John Health System, said the hospital reduced its overall readmission rate by 9 percent since the last quarter of 2011 through a variety of efforts. Patients are screened for readmission risk, and complex cases receive extra follow-up, Pazzo said in an email.

"As part of the overall effort, we are emphasizing better communication among providers, family members and caregivers so they are empowered to manage follow-up care," she said.

The Center for Medicare and Medicaid Services released data on the fines on its website last week.

The fines vary widely by geography, with 14 of 22 hospitals in the Oklahoma City area receiving no fine and all but one receiving relatively low fines compared to Tulsa hospitals, the World's analysis shows. Midwest Regional Medical Center in Midwest City received the highest fine in that area, 0.77 percent.

Out of 14 hospitals in Tulsa and its suburbs, six received no fine.

A Durant hospital - the Medical Center of Southeastern Oklahoma - was among 19 hospitals in the nation to receive the full 2 percent penalty. A "60 Minutes" broadcast last year alleged the hospital and the company that owns it pressured doctors to admit patients regardless of medical need.

Harmon Memorial Hospital in Hollis received a 1.89 percent penalty, ranking it among the 25 largest fines nationally.

Last year, the hospital, operated by the Harmon County Healthcare Authority, and one of its doctors agreed to pay $1.5 million to settle claims of health-care fraud in the Medicare and Medicaid programs. The payment settled a whistleblower lawsuit brought by a former administrator of the authority.

Officials with the Durant and Hollis hospitals could not be reached for comment.

Rick Snyder, vice president of finance and information services with the Oklahoma Hospital Association, said hospitals in the state were prepared for the fines, also levied last year.

"We've been actively working with hospitals to reduce readmissions," Snyder said.

LaWanna Halstead, vice president of quality and clinical initiatives for the association, said 55 Oklahoma hospitals are taking part in a network focusing on 10 ways to improve patient outcomes. Those include avoiding blood clots, hospital-acquired infections and patient readmissions.

"It's a very complicated issue," Halstead said.

In the Tulsa area, Hillcrest Medical Center received the largest penalty, 0.62 percent of future Medicare billings. The fine was lower than last year's penalty, which was the maximum 1 percent.

Angela Peterson, a spokeswoman for Hillcrest, said a new program at the hospital pairs registered nurses with patients who are at risk for readmission. The nurses, called Care Partners, work closely with patients to ensure they follow discharge instructions and can get to follow-up appointments.

"Readmission to the hospital within 30 days is often not an issue of care provided in the hospital but is often the result of circumstances after a patient leaves the hospital," Peterson said.

Saint Francis' hospitals at 61st and Yale and 10501 E. 91st St. were among Oklahoma hospitals penalized.

Saint Francis received a penalty that represents less than half of 1 percent of all future Medicare billings in the coming fiscal year. The hospital estimates that will total about $360,000 in the next fiscal year.

Aran said the program penalizes hospitals even if the reason for the patient's second hospital admission has nothing to do with the first admission.

"With the readmissions program, two out of three hospitals (nationally) get penalized with this strict bar. That's why hospitals all over the country are working like we are to reduce readmission," Aran said.

Dale Bratzler, associate dean and professor at the University of Oklahoma's College of Public Health, was among the authors of a 2011 medical study on readmissions.

The study found that about one in five Medicare patients, 17 percent, hospitalized for pneumonia returned to the hospital within 30 days.

Bratzler, an osteopathic physician, said readmission rates are higher for some diagnoses. One in four Medicare patients treated for heart failure return within 30 days, he said.

To determine the readmission penalty, the federal government examines the rate at which Medicare patients with certain illnesses return to any hospital within 30 days of being treated. The rates are adjusted for patients with more severe illnesses, but some hospitals still end up on the losing end.

"All the hospitals will tell you that if you have patients who have less access to care, they are more likely to be readmitted," Bratzler said.

Hospitals won't be able to prevent all patients from returning after discharge but by coordinating with outside care providers, they can improve outcomes, he said.

"Most experts feel that up to half of readmissions may be preventable with better coordination of care across settings. Again, that may vary by diagnosis. The 'correct' readmission rate is not zero, but Medicare feels that it can certainly be better than 20 percent."

Top 10 readmission fines

Here are the top 10 Oklahoma hospitals with the largest penalties for patient readmissions:

BY DANIEL CHANG

Most South Florida hospitals are improving their quality of care by one important measure under federal healthcare reform: reducing the number of Medicare patients readmitted within a month, according to recently released government data analyzed by Kaiser Health News.

But while many hospitals in Broward and Miami-Dade counties have reduced their readmission rates, Medicare identified 30 hospitals in the region that remained too high. Those hospitals will receive lowered Medicare reimbursement payments for one year beginning Oct. 1 as part of the government program’s efforts to pay healthcare providers for the quality of care they deliver and not just the number of patients they serve.

The effort seems to be working: Of the 35 area hospitals included in the federal data, a majority — 22 — received decreased penalties for 2014 compared to the prior year. Only five South Florida hospitals met Medicare’s readmission standards and will not be penalized at all, up from the three that received no penalty in 2013. And nearly a dozen — including Memorial Regional in Hollywood and Palm Springs General in Hialeah — will pay bigger fines.

The readmissions reduction program, which began in October 2012, is one of Medicare’s toughest, in part because there is no reward for improvements, and it’s not optional. Penalties for 2014 are based on readmissions of Medicare patients who originally were admitted to a hospital for a heart attack, heart failure or pneumonia and were discharged between July 2009 and June 2012.

Patients readmitted to any hospital within 30 days counted against the discharging hospital, unless the readmission had been planned when the patient originally left the hospital.

Hospitals that had more readmissions than Medicare predicted after adjusting for the severity of patients’ illnesses received a reduction in total payments.

Because Medicare applies the penalties to every payment for a patient stay, hospitals can only estimate the dollar amount of the fines.

One example: At Jackson Health System in Miami, penalties totaled about $900,000 for the year, hospital administrators said. Jackson’s penalty rate was .85 percent and dropped to .73 percent for 2014.

Healthcare experts believe the program will work to improve the overall quality of hospital care while helping to control medical costs by reducing readmissions.

The Medicare Payment Advisory Commission (MedPAC), which reports to Congress, has estimated that 12 percent of Medicare patients may be readmitted for potentially avoidable reasons. Preventing one out of every 10 of those readmissions could save Medicare $1 billion, MedPAC says.

Sal Barbera, a former hospital executive who teaches healthcare administration at Florida International University, said Medicare’s readmission reduction program has forced hospital administrators across the country to assume additional responsibilities at their own expense to ensure the well-being of their discharged patients

“It’s going to really move hospitals toward looking further than, ‘Hey, here’s a patient to discharge,’ ’’ Barbera said. “Now they’re going to have to look at the support a patient has when they go home. Who’s going to watch after them? Do they have a home? Do they need more education on medication?’’

Some South Florida hospitals are opening pharmacies on site so they can send patients home with medications, Barbera said, noting that patients’ failure to fill a prescription or follow instructions for medication frequently leads to readmissions.

At Memorial Regional in Hollywood, pharmacists and case managers visit the homes of targeted elderly patients after discharge to ensure they are taking prescribed medications, eating appropriate diets and making follow-up appointments with primary care physicians, said Dr. Stanley Marks, chief medical officer and senior vice president for Memorial Healthcare System, which includes Memorial Regional, Memorial West, Memorial Pembroke and Memorial Miramar.

“Those are the kinds of things — reconciling the medications that people are on, assuring they have an appointment with their primary care physician, assuring that the environment is safe for them to go home — that can actually decrease readmissions,’’ Marks said. “There’s a lot of responsibility placed on the hospital, and we’re responding.’’

Yet despite such programs, Memorial Regional was one of two South Florida hospitals whose readmission penalties increased to more than 1 percent from 2013 to 2014.

Memorial’s three other hospitals, however, all had their readmission penalties reduced from 2013 to 2014.

Marks said Memorial Regional “does tend to get sicker patients than the other hospitals,” and also skews to what he calls the “super elderly’’ or those over the age of 85 years old. The hospital also sees a higher number of Medicaid and indigent patients than its sister hospitals.

Reducing readmissions can be a challenge, he said, because physicians and nurses are effective at delivering care to patients in hospitals, not on the outside, where patients can no longer be as closely monitored.

“That becomes the real challenge,’’ he said. “Who is that population of patients that’s at higher risk for not doing what they’re supposed to be doing? Who’s going to go home and their first stop is going to be McDonald’s if they’re in congestive heart failure?’’

Healthcare experts agree that elderly patients with multiple medical conditions can be difficult to keep out of the hospital. Hospitals that treat large numbers of poor people also have been disproportionately affected by Medicare readmission penalties nationwide, though locally some of those safety net hospitals performed very well.

Broward Health Medical Center in Fort Lauderdale, a safety net hospital for Broward County, is one of five South Florida hospitals that will receive no penalty from Medicare next year after sufficiently reducing readmissions. Last year, Broward Health received a penalty of .19 percent.

The hospital serves a significant number of Medicaid and indigent patients, said Dr. Marc Bivins, medical director for quality and clinical resource management.

Bivins said Broward Health administrators, physicians, nurses, home health workers and case managers began working on reducing readmissions several years ago when they realized federal healthcare reform would focus on correcting the incentive hospitals have to readmit patients: More readmissions result in more billing.

Broward Health uses a patient assessment before discharge and “transition coaches” to visit discharged patients at home, ensuring they follow medical instructions and receive needed support. Broward Health also established “continuity clinics” at the hospital to improve access to primary care physicians for indigent patients, Bivins said. Preventive care is considered key to reducing hospital stays.

The hospital’s readmission reduction efforts are applied to all patients, he said.

“We feel like appropriate care is something we should be delivering to everyone,’’ Bivins said.

Jackson Health System, Miami-Dade’s public hospital network, takes a similar approach to reducing readmissions by assessing targeted patients while they are still hospitalized and sending “health coaches’’ to their homes after discharge, said Kevin Andrews, vice president and chief quality officer.

Patients with any of about 25 diagnoses, including diabetes and hypertension, are paired with a “nurse navigator” who assesses their needs, helps with appointments with doctors, nutritionists and social workers, and educates patients about disease progression and navigating the healthcare system.

Jackson also established “transitional clinics’’ in the community exclusively for discharged patients because the hospital system’s primary care clinics were backlogged, Andrews said.

At the transitional clinics, discharged patients can receive a follow-up visit with a physician or a nurse practitioner, typically within seven to 10 days after leaving the hospital. The goal is to change patient behavior so they visit the doctor regularly and learn to manage chronic conditions such as heart disease and diabetes.

“There’s no magic bullet,’’ Andrews said of reducing readmissions, “and it’s not one thing.’’

For 2014, Medicare will increase the maximum possible penalties to 2 percent of the total payments. And for 2015, that number goes to 3 percent — the same year that the federal healthcare law will add hip and knee surgery and chronic obstructive pulmonary disease to the list of conditions used to determine the penalties.

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

The Affordable Care Act imposes reductions in Medicare reimbursements to hospitals with too many patient readmissions. Below is a list of area hospitals, with their fiscal year 2013 readmission penalty, FY 2014 penalty, and percentage of change.

Nine hospitals in a region that stretches from Bedford to Tazewell will see their Medicare reimbursements cut this year for having too many patient readmissions.

The penalties, part of the new federal health care law, are aimed at prodding hospitals nationwide to do a better job of making sure that patients admitted with heart problems and pneumonia don’t wind up back in the hospital too quickly.

Starting in October, hospitals in the region will have their Medicare payments docked from .03 percent to 1.6 percent.

The government program — described as a “blunt instrument” by one hospital industry advocate — has resulted in payment reductions for about two-thirds of the nation’s hospitals.

A total of $227 million will be withheld from 2,225 hospitals in the coming fiscal year, according to Kathryn Ceja, a spokeswoman for the U.S. Centers for Medicare & Medicaid Services.

In the Roanoke and New River valleys, all four LewisGale hospitals and five run by Carilion Clinic will have their payments reduced.

The hospital with the highest readmission rate, LewisGale Hospital Pulaski, will face the toughest penalty — 1.6 percent of its Medicare reimbursements for a year, beginning Oct. 1.

Affected to a lesser degree were the region’s two major hospitals, LewisGale Medical Center in Salem and Carilion Roanoke Memorial Hospital. Payments to LewisGale will be reduced by .81 percent; the penalty for Roanoke Memorial will be .05 percent.

The penalties are part of a program that took effect last year under the Patient Protection and Affordable Care Act.

In an effort to cut down on avoidable hospital readmissions, government regulators are monitoring how many Medicare patients suffering from three ailments — heart failure, heart attacks and pneumonia — were readmitted within 30 days of their release.

How a hospital compares to the national average, once risk factors are taken into consideration, determines whether it will face a reduction in payments from Medicare, the government insurance program that covers senior citizens.

In 2010, about one in five Medicare patients was readmitted to a hospital within 30 days of their initial stay, according to CMS. That cost the program $17.5 billion — a sum the government hopes to trim by making it financially advantageous for hospitals to find ways to prevent readmissions.

When the program began last year, the maximum penalty was 1 percent of Medicare payments. That increases to 2 percent this year, and will reach 3 percent in fiscal year 2015.

Carilion officials said the move to reduce readmissions is consistent with their ongoing efforts to improve patient care. Converting to a clinic model, which offers multi-specialty physician services as opposed to just running a chain of hospitals, was key part of that initiative, they said.

“I don’t look upon this as a cost,” Dr. Wayne Gandee, chief medical officer for Carilion, said of the penalty program.

“I look at it as an investment in the care of patients.”

Based on historical averages, Carilion lost an estimated $267,000 in Medicare payments during the first year of the program. Looking forward, that amount is expected to drop to $179,000 in the year starting Oct. 1, according to Don Halliwill, the health system’s chief financial officer.

Carilion officials said the reduction in penalties, which comes even as the potential punishment doubles, is a testament to their success in reducing readmissions.

For a health care system that had $1.3 billion in revenues during the most recently completed fiscal year, $446,000 in lost Medicare payments might not sound like a lot.

But Medicare is one of the biggest payers to hospitals, “so any cut to reimbursements can add up to a lot,” said Chris Bailey, senior vice president of the Virginia Hospital and Healthcare Association.

While the association supports the government’s efforts to reduce readmissions, it has some concerns about the process.

For example, a provider can be held responsible for a readmission if a heart attack patient goes back to a hospital within 30 days of their release, even if it’s for something totally unrelated to their first stay, such as injuries from an automobile accident.

“This is a fairly blunt instrument that could use significant refinement,” Bailey said.

Another criticism is that the program unfairly punishes hospitals that treat the largest number of low-income patients.

Those patients are more likely to come from communities where there’s less access to transportation, pharmacies and other services needed for a speedy recovery.

“Hospitals want to be held accountable,” said Akin Demehin, senior associate director of policy for the American Hospital Association. “But on the other hand we think it’s unfair that hospitals are being held accountable for community-based factors that, at the end of the day, are very difficult for us to control.”

At LewisGale, a spokeswoman said that while the Centers for Medicare & Medicaid Services has ranked the four hospitals among the best in the nation for the three conditions measured by the program — heart attacks, heart failure and pneumonia — there’s always room for improvement.

“We certainly view this as an opportunity to improve on our readmission rates,” spokeswoman Joy Sutton said. “This data is several years old and since that time we’ve implemented several new initiatives. As a result, we’ve already noticed an improvement in our readmission rates based on our own tracking process for our hospitals.”

LewisGale declined to say how much money it has lost in Medicare payments under the program.

“These new initiatives have focused on helping our patients become more compliant with discharge instructions and medication compliance as well as working with key community partners, such as nursing homes, to share discharge information on our patients to ensure appropriate follow up care,” Sutton said in a prepared statement.

Two hospitals in the region owned by Carilion, in Giles County and Lexington, are reimbursed by Medicare under a different system and did not fall under the penalty program.

At Roanoke Memorial, the most recent readmission rate for heart attack patients was 18.1 percent, slightly below the national average. The readmission rate for heart failure was also below the average.

Carroll, Iowa -- St. Anthony Regional Hospital in Carroll was recently among the top 5,000 hospitals nationwide to be ranked as “highest or very high” in overall ratings when it comes to patient satisfaction. The poll released by U.S. News is based on responses given by patients from August 2011 to August 2012. When patients were asked if they’d recommend St. Anthony the ranking was above both the state and national averages, with 81% responding “definitely.”

Protocols the hospital has put in to place include instituting time-out before surgery, controlling pain, and using two patient identifiers. Karen Timm, Vice President for Patient Services says the hospital will continue to find new ways to provide exceptional care and services, and that they are extremely proud of the extra efforts the physicians, nurses, and staff put in to improving patient care.

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